Opioid use disorder

Opioid intoxication Signs and symptoms of opioid intoxication include: • Decreased perception of pain • Euphoria • Confusion • Desire to sleep • Nausea • Constipation • Miosis (pupil constriction) • Bradycardia (slow heart rate) • Hypotension (low blood pressure) • Hypokinesis (slowed movement) • Head nodding • Slurred speech • Hypothermia (low body temperature) Opioid overdose . 2 mg (white powder to the right) is a lethal dose in most people. US penny is 19 mm (0.75 in) wide. Signs and symptoms of opioid overdose include, but are not limited to: • Pin-point pupils may occur. Patient presenting with dilated pupils may still be experiencing an opioid overdose. • Decreased heart rate • Decreased body temperature • Decreased breathing • Altered level of consciousness. People may be unresponsive or unconscious. • Pulmonary edema (fluid accumulation in the lungs) • Shock • Death 10 mg, number facing up; the squares in the image represent one half centimeter, so the pill is around 0.75 cm in diameter. Withdrawal Opioid withdrawal can occur with a sudden decrease in, or cessation of, opioids after prolonged use. Onset of withdrawal depends on the half-life of the opioid that was used last. With heroin this typically occurs five hours after use. With methadone, it may take two days. Less significant symptoms may remain longer, in which case the withdrawal is known as post-acute-withdrawal syndrome. • Agitation • Anxiety • Muscle pains • Increased tearing • Trouble sleeping • Runny nose • Sweating • Yawning • Goose bumps • Dilated pupils • Diarrhea • Fast heart rate • High blood pressure • Abdominal cramps • Shakiness • Cravings • Sneezing • Bone pain • Increased body temperature • Hyperalgesia • Ptosis (drooping eyelids) • Teeth chattering • Emotional pain • Stress • Weakness • Malaise • Alexithymia • Dysphoria Treatment of withdrawal may include methadone and buprenorphine. Medications for nausea or diarrhea may also be used. ==Cause==

Opioid use disorder can develop for many reasons, including systemic failures such as pervasive marketing strategies, over-prescribing, and self-medication. Scoring systems have been derived to assess the likelihood of opiate addiction in chronic pain patients. Healthcare practitioners have long been aware that despite the effective use of opioids for managing pain, empirical evidence supporting long-term opioid use is minimal. Many studies of patients with chronic pain have failed to show any sustained improvement in their pain or ability to function with long-term opioid use. ==Mechanism==

Addiction Addiction is a chronic brain disorder characterized by compulsive drug use despite adverse consequences. Addiction involves the overstimulation of the brain's mesocorticolimbic reward circuit (reward system), essential for motivating behaviors linked to survival and reproductive fitness, like seeking food and sex. This reward system encourages associative learning and goal-directed behavior. In addiction, substances overactivate this circuit, causing compulsive behavior due to changes in brain synapses. In the brain's mesolimbic region, Nucleus Accumbens (NAc) accepts releases of dopamine triggered by the neurotransmitters. The brain reward circuitry is rooted in these networks, interacting between the mesolimbic and prefrontal cortex; these systems link motivation, anti-stress, incentive salience, and wellbeing. The incentive-sensitization theory differentiates between "wanting" (driven by dopamine in the reward circuit) and "liking" (related to brain pleasure centers). This explains the addictive potential of non-pleasurable substances and the persistence of opioid addiction despite tolerance to their euphoric effects. Addiction surpasses mere avoidance of withdrawal, involving cues and stress that reactivate reward-driven behaviors. plays a major role in opioid addiction. Overexpression of the gene transcription factor ΔFosB in the nucleus accumbens plays a crucial role in the development of an addiction to opioids and other addictive drugs by sensitizing drug reward and amplifying compulsive drug-seeking behavior. Like other addictive drugs, overuse of opioids leads to increased ΔFosB expression in the nucleus accumbens. Opioids affect dopamine neurotransmission in the nucleus accumbens via the disinhibition of dopaminergic pathways as a result of inhibiting the GABA-based projections to the ventral tegmental area (VTA) from the rostromedial tegmental nucleus (RMTg), which negatively modulates dopamine neurotransmission. In other words, opioids inhibit the projections from the RMTg to the VTA, which in turn disinhibits the dopaminergic pathways that project from the VTA to the nucleus accumbens and elsewhere in the brain. This study helps to show the contribution of dopamine receptors to substance addiction and more specifically to opioid abuse. Chronic intake of opioids such as heroin may cause long-term effects in the orbitofrontal area (OFC), which is essential for regulating reward-related behaviors, emotional responses, and anxiety. Moreover, neuroimaging and neuropsychological studies demonstrate dysregulation of circuits associated with emotion, stress and high impulsivity. Dependence Opioid dependence can occur as physical dependence, psychological dependence, or both. Opioid dependence can manifest as physical dependence, psychological dependence, or both. As a result of downregulated signaling through these proteins, opiates cause VTA neuronal hyperexcitability and shrinkage (specifically, the size of the neuronal soma is reduced). Upregulation of the cyclic adenosine monophosphate (cAMP) signal transduction pathway by cAMP response element binding protein (CREB), a gene transcription factor, in the nucleus accumbens is a common mechanism of psychological dependence among several classes of drugs of abuse. Selected results can be seen in the chart below. Heroin and morphine both scored highest, at 3.0. The pharmacogenomics of the opioid receptors and their endogenous ligands have been the subject of intensive activity in association studies. These studies test broadly for a number of phenotypes, including opioid dependence, cocaine dependence, alcohol dependence, methamphetamine dependence/psychosis, response to naltrexone treatment, personality traits, and others. 118A>G variant While over 100 variants have been identified for the opioid mu-receptor, the most studied mu-receptor variant is the non-synonymous 118A>G variant, which results in functional changes to the receptor, including lower binding site availability, reduced mRNA levels, altered signal transduction, and increased affinity for beta-endorphin. In theory, all these functional changes would reduce the impact of exogenous opioids, requiring a higher dose to achieve the same therapeutic effect. This points to a potential for greater addictive capacity in individuals who require higher dosages to achieve pain control. Non-opioid receptor genes While opioid receptors have been the most widely studied, a number of other genes have been implicated in OUD. Higher numbers of (CA) repeats flanking the preproenkephalin gene, PENK, have been associated with opiate dependence. There have been mixed results for the MCR2 gene, encoding melanocortin receptor type 2, implicating both protection and risk to heroin addiction. Genotyping of CYP2D6 in particular may play a role in helping patients with individualized treatment for OUD and other drug addictions. == Diagnosis ==

dose of fentanyl powder, on a pencil tip, is a lethal amount for most people. The DSM-5 guidelines for the diagnosis of opioid use disorder require that the individual has a significant impairment or distress related to opioid uses. To make the diagnosis two or more of 11 criteria must be present in a given year: • More opioids are taken than intended • The individual is unable to decrease the number of opioids used • Large amounts of time are spent trying to obtain opioids, use opioids, or recover from taking them • The individual has cravings for opioids • Difficulty fulfilling professional duties at work or school • Continued use of opioids leading to social and interpersonal consequences • Decreased social or recreational activities • Using opioids despite being in physically dangerous settings • Continued use despite opioids worsening physical or psychological health (i.e. depression, constipation) • Tolerance • Withdrawal The severity can be classified as mild, moderate, or severe based on the number of criteria present. The tolerance and withdrawal criteria are not considered to be met for individuals taking opioids solely under appropriate medical supervision. Addiction and dependence are components of a substance use disorder; addiction is the more severe form. == Prevention ==

Prevention approaches for opioid use disorder must consider clinical recommendations for prescribing/starting to take opioids, when they are clinically appropriate to use, and risks associated with opioid therapy. Improving opioid prescribing guidelines and practices can help reduce unnecessary exposure to opioids, which lowers the risk of developing OUD (opioid use disorder). Healthcare providers should strictly follow evidence-based guidelines to ensure safe and appropriate use. Another way to prevent OUD is by educating the public about the risks of prescription opioids and illegal substances like fentanyl. Awareness campaigns, community outreach programs, and school-based education initiatives can help people make informed decisions about opioid use and recognize the signs of addiction early. A strong association between adverse childhood experiences and opioid abuse later in life has been identified, suggesting that a high adverse childhood experiences score should be considered a risk factor for opioid abuse. It can be given by many routes (e.g., intramuscular (IM), intravenous (IV), subcutaneous, intranasal, and inhalation) and acts quickly by displacing opioids from opioid receptors and preventing the activation of these receptors. Naloxone kits are recommended for laypersons who may witness an opioid overdose, for people with large prescriptions for opioids, those in substance use treatment programs, and those recently released from incarceration. Since naloxone is a life-saving medication, many areas of the U.S. have implemented standing orders for law enforcement to carry and give it as needed. In addition, naloxone can be used to challenge a person's opioid abstinence status before starting a medication such as naltrexone, which is used in the management of opioid addiction. Good Samaritan laws typically protect bystanders who administer naloxone. In the U.S., at least 40 states have Good Samaritan laws to encourage bystanders to take action without fear of prosecution. As of 2019, 48 states give pharmacists the authority to distribute naloxone without an individual prescription. Homicide, suicide, accidents and liver disease are also opioid-related causes of death for those with OUD. Many of these causes of death are unnoticed due to the often limited information on death certificates. Other risk factors for overdose mortality related to opioids at the individual level include clinical factors such as cardiovascular disease, comorbid mental disorders and psychological stress (e.g., depression), a history of substance use disorders, economic and community distress (e.g., low education, high unemployment), and characteristics such as male sex and middle age. U.S. prevention strategies The CDC Clinical Practice Guideline for Prescribing Opioids for Pain was developed to help guide healthcare professionals toward safe and evidence-based use of opioid therapy. Large U.S. retail pharmacy chains are implementing protocols, guidelines, and initiatives to take back unused opioids, providing naloxone kits, and being vigilant about suspicious prescriptions. Many U.S. officials and government leaders have become involved in implementing preventative measures to decrease opioid usage in the U.S. Targeted education of medical providers and government officials can lead to provisions affecting opioid distribution by healthcare providers. == Mitigation ==

The "CDC Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022" provides recommendations related to opioid misuse, OUD, and opioid overdoses. It reports a lack of clinical evidence that "abuse-deterrent" opioids (e.g., OxyContin), as labeled by the U.S. Food and Drug Administration, are effective for OUD risk mitigation. CDC guidance suggests the prescription of immediate-release opioids instead of opioids that have a long duration (long-acting) or opioids that are released over time (extended release). For more specific mitigation strategies regarding opioid overdoses, see . ==Management==

Opioid use disorders typically require long-term treatment and care with the goal of reducing the person's risks and improving their long-term physical and psychological condition. First-line management involves the use of opioid replacement therapies, particularly methadone, naltrexone, morphine, hydromorphone, buprenorphine/naloxone, and diamorphine, which is the most effective treatment option of all drugs. Withdrawal management alone is strongly discouraged, because of its association with elevated risks of HIV and hepatitis C transmission, high rates of overdose deaths, and nearly universal relapse. This approach is seen as ineffective without plans for transition to long-term evidence-based addiction treatment, such as opioid agonist treatment. These periods of increased vulnerability are significant because many of those in treatment leave programs during these periods. Medication Opioid replacement therapy (ORT), also known as opioid substitution therapy (OST), Medication for Addiction Treatment (MAT), or Medications for Opioid Use Disorder (MOUD), involves replacing an opioid, such as heroin. Commonly used drugs for ORT are methadone and buprenorphine/naloxone (Suboxone), which are taken under medical supervision. and effects on the heart (QTc prolongation). Buprenorphine/naloxone, methadone, and naltrexone are approved by the U.S. Food and Drug Administration (FDA) for medication-assisted treatment (MAT). In the U.S., the Substance Abuse and Mental Health Services Administration (SAMHSA) certifies opioid treatment programs (OTPs), where methadone can be dispensed at methadone clinics. As of 2023, the Waiver Elimination (MAT Act), also known as the "Omnibus Bill", removed the federal requirement for medical providers to obtain a waiver to prescribe buprenorphine, in an attempt to increase access to OUD treatment. The driving principle behind ORT is the patient's reclamation of a self-directed life. ORT facilitates this process by reducing symptoms of drug withdrawal and drug cravings. The period when initiating methadone and the time immediately after discontinuing treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies. ORT is endorsed by the World Health Organization, United Nations Office on Drugs and Crime, and UNAIDS as effective at reducing injection, lowering risk for HIV/AIDS, and promoting adherence to antiretroviral therapy. and in the case of buprenorphine, a high-affinity partial opioid agonist, also due to opioid receptor saturation. Buprenorphine Buprenorphine can be administered either as a standalone product or in combination with the opioid antagonist naloxone. This inclusion is strategic: it deters misuse by preventing the crushing and injecting of the medication, encouraging instead the prescribed sublingual (under the tongue) route. these formulations operate efficiently when taken sublingually. In this form, buprenorphine's bioavailability remains robust (35–55%), while naloxone's is significantly reduced (~10%). Buprenorphine's role as a partial opioid receptor agonist sets it apart from full agonists like methadone. Its unique pharmacological profile makes it less likely to cause respiratory depression, thanks to its "ceiling effect". While the risk of misuse or overdose is higher with buprenorphine alone compared to the buprenorphine/naloxone combination or methadone, its usage is linked to a decrease in mortality. buprenorphine has since expanded in form, with the FDA approving a month-long injectable version in 2017. When initiating buprenorphine/naloxone therapy, several critical factors must be considered. These include the severity of withdrawal symptoms, the time elapsed since the last opioid use, and the type of opioid involved (long-acting vs. short-acting). A standard induction method involves waiting until the patient exhibits moderate withdrawal symptoms, as measured by a Clinical Opiate Withdrawal Scale, achieving a score of around 12. Alternatively, "microdosing" commences with a small dose immediately, regardless of withdrawal symptoms, offering a more flexible approach to treatment initiation. "Macrodosing" starts with a larger dose of Suboxone, a different induction strategy with its own set of considerations. Methadone Methadone is a commonly used full-opioid agonist in the treatment of opioid use disorder. It is effective in relieving withdrawal symptoms and cravings in people with opioid addiction, and can also be used in pain control in certain situations. While methadone is a widely prescribed form of OAT, it often requires more frequent clinical visits compared to buprenorphine/naloxone, which also has a better safety profile and lower risk of respiratory depression and overdose. Important considerations when initiating methadone include the patient's opioid tolerance, the time since last opioid use, the type of opioid used (long-acting vs. short-acting), and the risk of methadone toxicity. Methadone comes in different forms: tablet, oral solution, or an injection. Naltrexone Naltrexone is an opioid receptor antagonist used for the treatment of opioid addiction. It is not as widely used as buprenorphine or methadone for OUD due to low rates of patient acceptance, non-adherence due to daily dosing, and difficulty achieving abstinence from opioids before beginning treatment. Dosing naltrexone after recent opioid use can lead to precipitated withdrawal. Conversely, naltrexone antagonism at the opioid receptor can be overcome with higher doses of opioids. Naltrexone monthly IM injections received FDA approval in 2010 for the treatment of opioid dependence in abstinent opioid users. Other opioids Evidence of effects of heroin maintenance compared to methadone are unclear as of 2010. A Cochrane review found some evidence in opioid users who had not improved with other treatments. In Switzerland, Germany, the Netherlands, and the United Kingdom, long-term injecting drug users who do not benefit from methadone and other medication options may be treated with injectable heroin that is administered under the supervision of medical staff. Other countries where it is available include Spain, Denmark, Belgium, Canada, and Luxembourg. Dihydrocodeine in both extended-release and immediate-release form is also sometimes used for maintenance treatment as an alternative to methadone or buprenorphine in some European countries. Dihydrocodeine is an opioid agonist. It may be used as a second-line treatment. A 2020 systematic review found low-quality evidence that dihydrocodeine may be no more effective than other routinely used medication interventions in reducing illicit opiate use.An extended-release morphine confers a possible reduction of opioid use and with fewer depressive symptoms but overall more adverse effects compared to other forms of long-acting opioids. Retention in treatment was not found to be significantly different. It is used in Switzerland and Canada. In pregnancy Pregnant women with opioid use disorder can also receive treatment with methadone, naltrexone, or buprenorphine. Buprenorphine appears to be associated with more favorable outcomes compared to methadone for treating opioid use disorder (OUD) in pregnancy. Studies show that buprenorphine is linked to lower risks of preterm birth, greater birth weight, and larger head circumference without increased harm. Compared to methadone, it consistently results in improved birth weight and gestational age, though these findings should be interpreted with caution due to potential biases. Buprenorphine use correlates with a lower risk of adverse neonatal outcomes, with similar risks of adverse maternal outcomes as methadone. Infants born to buprenorphine-treated mothers generally have higher birth weights, fewer withdrawal symptoms, and a lower likelihood of premature birth. Behavioral therapy Paralleling the variety of medical treatments, there are many forms of psychotherapy and community support for treating OUD. The primary evidence-based psychotherapies include cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), contingency management (CM), and twelve-step programs. Community-based support such as support groups (e.g., Narcotics Anonymous) and therapeutic housing for those with OUD is also an important aspect of healing. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a form of psychosocial intervention that systematically evaluates thoughts, feelings, and behaviors about a problem and works to develop coping strategies to work through those problems. This intervention has demonstrated success in many psychiatric conditions (e.g., depression) and substance use disorders (e.g., tobacco). The use of CBT alone for OUD has declined due to lack of efficacy, and many rely on medication therapy or medication therapy with CBT, since both were found to be more efficacious than CBT alone. Motivational Enhancement Therapy Motivational enhancement therapy (MET) is the manualized form of motivational interviewing (MI). MI leverages one's intrinsic motivation to recover through education, formulation of relapse prevention strategies, reward for adherence to treatment guidelines, and positive thinking to keep motivation high—which are based on a person's socioeconomic status, gender, race, ethnicity, sexual orientation, and readiness to recover. Like CBT, MET alone has not shown convincing efficacy for OUD. There is stronger support for combining it with other therapies. Outpatient clients are shown to have improved medication compliance, retention, and abstinence when using voucher-based incentives. NA's 12-step process is based on the 12-step facilitation of Alcoholic Anonymous (AA) and centers on peer support, self-help, and spiritual connectedness. Some evidence also supports the use of these programs for adolescents. Multiple studies have shown increased abstinence for those in NA compared to those who are not. Members report a median abstinence length of 5 years. These results are consistent with the use of NIBS for reducing cravings of other substances. Investigations into the anecdotal evidence of psychedelics like ibogaine have also shown the possibility of decreased cravings and withdrawal symptoms. Emerging research includes the noribogaine analogue GM-3009, a next-generation neuroplastogen engineered to eliminate the cardiotoxicity of traditional ibogaine, with clinical Phase 1 trials commencing in 2026. Ibogaine is illegal in the U.S. but is unregulated in Mexico, Costa Rica, and New Zealand, where many clinics use it for addiction treatment. Research has shown a minor mortality risk due to its cardiotoxic and neurotoxic effects. Challenges The stigma surrounding addiction can heavily influence opioid addicts not to seek help. Stigma may arise from a variety of sources, including friends, family, employers, and healthcare providers. People who experience stigma related to their opioid use disorder are less inclined to seek out treatment or remain in treatment because of shame or feelings of being judged. Therefore, reducing stigma via education and support improves outcomes in the treatment of OUD and makes people more confident in seeking treatment. Many people view addiction as a moral failing rather than a medical condition, which can lead to feelings of shame and isolation. This stigma can affect family members, making it difficult for them to support their loved ones effectively. According to position papers on the treatment of opioid dependence published by the United Nations Office on Drugs and Crime and the World Health Organization, care providers should not treat opioid use disorder as the result of a weak moral character or will but as a medical condition. The exact mechanisms are unclear, leading to debate over the influence of biology and free will. Accessing appropriate treatment is often a significant barrier. Factors include: • Availability of services: Many areas, especially rural regions, lack treatment facilities or qualified healthcare providers who specialize in opioid use disorder. • Insurance coverage: People without insurance or those whose plans do not cover substance use disorder treatment may struggle to find affordable care. • Transportation: For many, getting to treatment facilities can be challenging due to a lack of transportation options. • Public stigma: Many communities may advocate against establishing treatment programs in their area due to stigma and perceptions of people with substance use disorders. The United States passed the Comprehensive Addiction and Recovery Act (CARA) in 2016, with the aim to remove treatment barriers by allocating federal funds to increase accessibility to Medication Opioid Use Disorder (MOUD) treatment in rural areas. Telehealth could be a beneficial treatment alternative, especially for people in rural areas with limited access to MOUD treatment. The variety of treatment modalities available for OUD—such as medication-assisted treatment (MAT), counseling, and residential programs—can be overwhelming. Patients may have difficulty understanding which option best suits them, leading to confusion and potential disengagement from the treatment process. Withdrawal symptoms can be severe and uncomfortable, leading many people to relapse before they complete detoxification or engage fully in recovery programs. The fear of withdrawal often prevents people from seeking help altogether. == Epidemiology ==

Globally, the number of people with opioid dependence increased from 10.4 million in 1990 to 15.5 million in 2010. Opioid use disorders resulted in 122,000 deaths worldwide in 2015, up from 18,000 deaths in 1990. Deaths from all causes rose from 47.5 million in 1990 to 55.8 million in 2013. The first wave began in the 1990s, related to the rise in prescriptions of natural opioids (such as codeine and morphine), semisynthetic opioids (oxycodone, hydrocodone, hydromorphone, and oxymorphone), and synthetic opioids like methadone. The age-adjusted drug poisoning death rate involving heroin doubled from 0.7 to 1.4 deaths per 100,000 people between 1999 and 2011 and continued to increase to 4.1 in 2015. The third wave of overdose deaths began in 2013, related to synthetic opioids, particularly illicitly produced fentanyl. The current, fourth wave, which began in 2016, has been characterized by polysubstance overdose due to synthetic opioids like fentanyl mixed with stimulants such as methamphetamine or cocaine. In 2010, around 0.5% of opioid-related deaths were attributed to mixture with stimulants. This figure increased more than 50-fold by 2021, when about a third of opioid-related deaths, or 34,000, involved stimulant use. The administration introduced a strategic framework called the Five-Point Opioid Strategy, which includes providing access recovery services, increasing the availability of reversing agents for overdose, funding opioid misuse and pain research, changing treatments of people managing pain, and updating public health reports related to combating opioid drug misuse. Studies done in the U.S. from 2010 to 2019 revealed that about 86.6% of people in the U.S. who could have benefited from opioid use disorder treatment were not receiving it. Over the past decade, the uptake of medications for opioid use disorder has increased, but there are still many regions with a prevalence of opioid use disorder and lack of medical support. The U.S. epidemic in the 2000s is related to a number of factors. and men also account for more opioid overdoses than women, although this gap is closing. Deaths due to opioid use also tend to skew at older ages than deaths from use of other illicit drugs. This does not reflect opioid use as a whole, which includes younger people. Overdoses from opioids are highest among people between the ages of 40 and 50, but the average age of first-time use of prescription painkillers was 21.2 years in 2013. Among the middle class, means of acquiring funds include elder financial abuse and international dealers noticing a lack of enforcement in their transaction scams throughout the Caribbean. Since 2018, with the federal government's passing of the SUPPORT (Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act) Act, federal restrictions on methadone use for patients receiving Medicare have been lifted. Since March 2020, as a result of the COVID-19 pandemic, buprenorphine may be dispensed via telemedicine in the U.S. In October 2021, New York Governor Kathy Hochul signed legislation to combat the opioid crisis. This included establishing a program for the use of medication-assisted substance use disorder treatment for incarcerated individuals in state and local correctional facilities, decriminalizing the possession and sale of hypodermic needles and syringes, establishing an online directory for distributors of opioid antagonists, and expanding the number of eligible crimes committed by individuals with a substance use disorder that may be considered for diversion to a substance use treatment program. Until these laws were signed, incarcerated New Yorkers did not reliably have access to medication-assisted treatment. Syringe possession was still a class A misdemeanor despite New York authorizing and funding syringe exchange and access programs. This legislation acknowledges the ways New York State laws have contributed to opioid deaths: in 2020 more than 5,112 people died from overdoses in New York State, with 2,192 deaths in New York City. In 2023, the Waiver Elimination (MAT Act), as part of Section 1262 of the Consolidated Appropriations Act, 2023 (or "Omnibus Bill"), removed the federal requirement for medical providers to obtain a waiver to prescribe buprenorphine, in an attempt to increase access to OUD treatment. File:NIDA overdose all.png|U.S. yearly deaths by drug category File:NIDA overdose heroin.png|U.S. yearly opioid overdose deaths involving heroin COVID-19 Epidemiological research has shown that the COVID-19 pandemic accelerated the opioid crisis. The overarching trend of opioid overdose data has shown a plateau in deaths around 2017–18, with a sudden and acute rise in 2019 primarily attributed to synthetic opioids like fentanyl. One JAMA review by Gomes et al. showed that estimated years of life loss (YLL) due to opioid toxicity in the U.S. increased by 276%. This increase was particularly felt by those ages 15 to 19, whose YLL increased nearly threefold. Younger male adults had the largest effect size. Telehealth played a large role in OUD treatment access, and legislation on telehealth continues to evolve. A study of Medicare beneficiaries with new-onset OUD showed that those who received telehealth services had a 33% lower risk of death by overdose. Minority groups such as Black and Hispanic Americans have also been shown to benefit from the increased access due to telehealth programs introduced during the pandemic, despite increasing disparity gaps in other OUD-related outcomes. The DEA and HHS have extended telemedicine flexibility in regard to prescribing controlled substances such as buprenorphine for OUD through 31 December 2024.\\ China China's relationship with opioids, particularly opium, dates back centuries, with significant use for medicinal purposes by the 7th century and increased demand in the 17th century due to smoking practices from Southeast Asia. The Opium Wars in the 19th century exacerbated the problem, leading to social and health crises. After 1949, under the Communist regime, strict legislation and punishment significantly reduced opioid use, creating a drug-free atmosphere by the 1950s. But with the economic reforms and open-door policies of the 1980s, drug abuse, including opiate dependence, reemerged as a major public health issue. From 2000 to 2020, the prevalence of OUD in China showed significant trends, though exact figures are hard to obtain due to underreporting. In 2004, Tang et al. reported approximately 1.14 million registered drug addicts, with over 75% being heroin addicts, suggesting a substantial burden, though the actual number is likely higher due to the hidden nature of drug use. Opioid abuse has been linked to significant health implications, particularly the spread of HIV/AIDS. In 2004, intravenous drug use was the most prevalent route of HIV transmission, accounting for 51.2% of cases, underscoring the public health threat. This suggests OUD and associated infectious illness therapies are needed. ==History==

. Historical misuse Opiate misuse has been recorded at least since 300 BC. Greek mythology describes Nepenthe ("free from sorrow") and its use by the hero of the Odyssey. Opioids have been used in the Near East for centuries. They were purified and isolated in the early 19th century. In the early 2000s, buprenorphine was one of the first opioid dependence drugs approved in the U.S. to combat opioid abuse, after decades of research led to the development of drugs to fight opioid use disorder. Historical treatment Levacetylmethadol (LAAM) was formerly used to treat opioid dependence. In 2003, its manufacturer discontinued production. There are no available generic versions. LAAM produced long-lasting effects, which allowed the person receiving treatment to visit a clinic only three times per week, as opposed to daily as with methadone. In 2001, LAAM was removed from the European market due to reports of life-threatening ventricular rhythm disorders. In 2003, Roxane Laboratories, Inc. discontinued it in the U.S. == Treatment record confidentiality ==

Patient records from opioid use disorder treatment programs receiving federal assistance are subject to 42 CFR Part 2, federal regulations that provide confidentiality protections beyond those afforded to general medical records. These protections, originally enacted to encourage people to seek treatment for substance use disorders without fear of prosecution or discrimination, restrict the disclosure of identifying information about patients in SUD treatment programs and generally require specific written patient consent before records can be shared. The strict consent requirements of Part 2 created challenges for opioid treatment programs participating in OTP networks and prescription drug monitoring programs (PDMPs), as the regulations limited sharing of patient information for care coordination purposes. A February 2024 final rule implementing Section 3221 of the CARES Act addressed these barriers by aligning Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. The rule allows patients to provide a single consent for all future disclosures for treatment, payment, and health care operations, enabling opioid treatment programs to share information more readily with other healthcare providers involved in a patient's care. The rule maintained the prohibition on using Part 2 records in criminal proceedings without a court order and applied HIPAA breach notification requirements to SUD treatment records for the first time, with a compliance date of February 16, 2026. == References ==